Join our Emergency General Surgery team as they discuss Necrotizing Soft-Tissue Infections. Hosted by Drs. Jordan Nantais, Ashlie Nadler, Stephanie Mason and Graham Skelhorne-Gross.
Necrotizing Soft-Tissue Infections:
– Also known as “flesh eating disease”, gas gangrene, necrotizing fasciitis/myositis, Fournier’s gangrene.
– Early findings are non-specific
– Rapidly fatal – diagnostic delay can lead to tremendous additional morbidity and mortality
– Type 1 – polymicrobial category (most common) found in immunosuppressed or elderly
– Type 2 – monomicrobial infection [Group A Streptococcus > Methicillin-resistant Staphylococcus aureus (MRSA)]
– Type 3 – monomicrobial infection (Vibrio or Clostridium)
– Type 4 – fungal (rare) in immunocompromised or after penetration or trauma from candida or Zygomycetes.
– History: (comorbidities, immunosuppression, recent infections or trauma)
– Exam: swelling, open lesions, drainage, erythema, crepitus, and pain out of proportion
– Most common: swelling, pain, erythema
– Bullae, skin necrosis, crepitus are less common
– Labs: Hb, wbc, Na, Creat, glucose, and CRP
– Imaging: CT, MRI *sensitive and specific but may not change management
– Cut-down: bedside vs in OR
– Gm stain
– Initially: two large bore IVs, foley catheter, aggressive fluid resuscitation, broad spectrum antibiotics, vasopressors PRN
– Abx choices: carbopenem or piperacllin-tazobactam or cefotaxime plus metronidazole. Clindamycin (antitoxin effect) and vancomycin (MRSA) should be considered.
– OR: must debride all dead/infected tissue, involve other surgical specialties as needed
– Mark edge of cellulitis and use as initial debridement
– Healthy dermis – pearly and white
– Healthy fat – pale, yellow, glistening
– Healthy fascia – should bleed, doesn’t easily separate from muscle
– Healthy muscle – contract with cautery
– Dressing: betadine-soaked gauze on the wound
– Most patients will need at least 3 ORs (second OR generally 8-12 hours after the first)
– No VAC or stoma at first OR
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